GW1-2022-06797_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Mike Tynan "14;WXTERZONES
FROM TO DESCRIPTION
Well Contractor Name 20 ft. 47 ft. pwr
2725-A
ft. ft. I ,
NC Well Contractor Certification Number "I5:OUTER CASING(fnrmultrcased,'ive0s)'OR=L'INER'if a' hcnble
IET (Innovative Environmental Technologies) FROM TO DIll1tE1ER THICKNESS 11fATERiAL
ft. rt. in.
Company Name WM0501 490
t16.INNER GASING OR TUBING; e'otheimal closed loo
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11C,County,State,Variance,etc.) 0 ft, 42 ft- 2 1° 1 SCh40 PVC
3.Well Use(check well use): ft. FL in.
CREE
Water Supply Well: FROM TO DIAMETER i ;SLOTSIZE THICK
NESS MATERIAL
Agricultural IOMunicipal/Public 42 ft, 47 ft, 2 1n- 0.010 1 SCh40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in
Industrial/Commercial OResidential Water Supply(shared) 118•,GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 3 ft. concrete pour
X Monitoring_ _ []Recovery 3 It- 40 R- bentonite', pour_ - - -
Injection Well:
ft. rt.
Aquifer Recharge OGroundwater Remediation
_ d9.'SAND/GRAVEL PACK.ifs 'licnble '
` Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test IOStormwaterDrainage 40 ft 47 ft- #2 silica sand Itrernie
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ITracer a20:DRILLING LOG attach additiiinaLsheeis if necessary)
' Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TOJISESCRIPTION colon hardness,solurock a°rain size etc,
0 ft- 10ilty sand
4.Date Well(s)Completed:7/5/22 Well ID#MW210 ft• 1811htbrown wr
5a.Well Location: 18 It, 28ll ht re wr
Self Help Ventures Fund 28 ft 32light brown pwr
Facility/Owner Name Facility ID#(if applicable) 32 ft. 44 1 light grey pwr
906 Carroll St, Durham, 27701 44 fL 47 ft. I light brown pwr
Physical Address,City,and Zip ft. ft l l
,,. ,aa
Durham ,:2IC REIAiARKS L'.i7
County Parcel Identification No.(PIN) MW completed at surface with flush cover, lock and 2'x2'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: concrete pad.
(if well field,one lat/long is sufficient) 22.Certification:
35.992656 N 78.916490 w
/ 7/10/22
6.Is(are)the well(s)oPermanent or OTemporary Signature of Gglied Well Contractor ' Date
By signing this forn,-1hereby cert fv that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: FlYes or E)No with 15A NCAC 02C.0100 a•15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known tireli construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under*21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GWA is needed. Indicate TOTAL NUMBER of wells construction details. You may also,attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS',
9.Total well depth below land surface:4 7 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example 0 200'and 2@a 100') construction to the following: j
GG
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service enter,Raleigh,NC 27699-1617
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11.Borehole diameter: 4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Auger &Air Rotary above,also submit one copy of tliislform within 30 days of completion of well
12.Well construction method: construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016